Basic Information
Provider Information | |||||||||
NPI: | 1902090780 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HAWKINS | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | LEIGH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LPC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TUCKER | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | LEIGHT | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LPC | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1316 SOMERVILLE RD SE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | DECATUR | ||||||||
State: | AL | ||||||||
PostalCode: | 356014305 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563556105 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 295 HOSPITAL ST | ||||||||
Address2: |   | ||||||||
City: | MOULTON | ||||||||
State: | AL | ||||||||
PostalCode: | 356501210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2569746697 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/05/2007 | ||||||||
LastUpdateDate: | 04/25/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 101YP2500X | 3203 | AL | Y |   | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.